Psychiatry Flashcards
1
Q
What is the structure of a psychiatric history?
A
HPC - onset, duration, stressors
PMH - physical and mental health
FH - history of mental health and relationship with family
SH - housing, money and employment and substance abuse
PH - How was childhood, home environment, developmental milestones, school participation and enjoyment, and previous abuse?
Forensic history - offender/prison or victim
Premorbid history - how were they before their condition, strength and assets, hobbies and interests
2
Q
What are the different parts of a mental state examination?
A
Appearance and behavior (psychomotor disorders, tremors, engagement, eye contact)
Speech - rate, tone, volume
Mood and affect - current mood and variation, is mood and affect congruent?
Thoughts - content –> delusions, obsessions, compulsions
- form –> loosening of associations, though blocking. flight
of ideas, Circumstantial, tangential
Perception - Hallucinations
Cognition-oriented in date, place, and time?
Insight - do they believe they need help, do they agree they need help, do they feel they have to take meds and are they working?
3
Q
What is the DSM - V definition of ADHD?
A
A condition that incorporates features relating to inattention and/or hyperactivity/impulsivity that is persistent
4
Q
What are the diagnostic criteria for ADHD?
A
Element of developmental delay.
For children up to the age of 16 years, six of these features have to be present; in those aged 17 or over, the threshold is five features
5
Q
What are the diagnostic features of inattention in ADHD?
A
Does not follow through on instructions
Reluctant to engage in mentally intense tasks
Easily distracted
Finds it difficult to sustain tasks
Finds it difficult to organize tasks or activities
often loses things that are necessary for tasks and activities
often does not seem to listen when spoken to directly
6
Q
What are the diagnostic features of hyperactivity/impulsivity in ADHD?
A
Unable to play quietly
Talks excessively
Does not wait their turn easily
will spontaneously leave their seat when expected to sit
Is often on the go
Often interruptive and intrusive of others
Will answer prematurely, before a question has been finished
Will run and climb in situations where it is not appropriate.
7
Q
What is the management of ADHD
A
Following the presentation, a ten-week wait-and-watch period should follow to observe
If sx persists then referral to secondary care e.g CAHMS
Drug therapy last resort and only for those over 5 years old
First line –> methylphenidate (CNS stimulant - dopamine/norepinephrine reuptake inhibitor), the first line in children, Side-effects include abdominal pain, nausea and dyspepsia
Second line –> if no response with methylphenidate then switch to lisdexamfetamine
Third line –> Dexafetamine - who can’t handle lisdexamfetamine side effects
8
Q
What are the criteria for diagnosis of depression?
A
–> Symptoms >2 weeks
–> Symptoms not due to alcohol, drugs, medication, or bereavement
–> The patient experiencing ≥5 symptoms, which must include either depressed mood AND/OR anhedonia
Symptoms must cause sig distress or impairment in social, occupational, or other areas of functioning
9
Q
What are the core symptoms of depression?
A
S –> sleep changes e.g more or less sleep or early morning awakening
I –> loss of interests - anhedonia
G –> guilt or feeling of worthlessness
E –> energy changes, feeling tired
C –> changes in concentration
A –> appetite changes
P –> psychomotor agitation or retardation
S –> suicidal thoughts or acts
10
Q
what are the somatic symptoms found in depression?
A
loss of emotional reactivity
Diurnal mood variation
anhedonia
early morning awakening
GI upset
headaches
11
Q
What are the psychotic symptoms of depression
A
Delusions, e.g., poverty, personal inadequacy, guilt over presumed misdeeds, responsibility for world events, deserving of punishment and other nihilistic delusions
Hallucination, e.g., auditory (defamatory/accusatory and cries for help/screaming), olfactory (bad smells) and visual (tormentors, demons and The Devil etc.)
Catatonic symptoms –> marked psychomotor retardation such as depressive stupor
12
Q
What is the DSM-V grading for depression severity?
A
–> Mild depression: 5 core symptoms + minor social/occupational impairment
–> Moderate depression: ≥5 core symptoms + variable degree of social/occupational impairment
–> Severe depression: ≥5 core symptoms + significant social/occupational impairment - can occur with or without psychotic symptoms.
At least 1 core symptom must be depressed mood OR anhedonia.
Subthreshold depressionis diagnosedif the person has at least 2, but fewer than 5 coresymptoms of depression
13
Q
What are the subtypes of depression?
A
–> Dythmic disorder
–> post-natal depression
–> seasonal affective disorder
14
Q
Describe the investigations for depression
A
–> psych Hx +MSE
–> patient health questionnaire - 9 (PHQ-9)
–> Hospital anxiety and depression scale (HADS)
Baseline Investigations
–> FBC, ESR, B12/folate, U&Es, LFTs, TFTs, glucose and Ca2+
Focused investigations
–> ANA for vasculitides that could be causing headaches or general fatigue, urine/blood toxicology, ABG, thyroid antibodies, dexamethasone suppression test (Cushing’s disease), CT/MRI head
15
Q
What is the treatment for depression?
A
–> Cognitive behavioral therapy (CBT)
–> Antidepressants
First line: SSRIs, e.g., paroxetine, citalopram, fluoxetine, or sertraline (consider gastroprotection i.e., PPI)
SNRIs: duloxetine and venlafaxine
TCAs: Sedating (e.g., amitriptyline or clomipramine) and non-sedating (e.g., imipramine and lofepramine)
Alpha2-adrenoreceptor antagonist: Mirtazapine
MAOi: Isocarboxazid or Phenelzine sulfate
Information to patient: vigilant for worsening depressive symptoms, usually takes 2–4weeks for symptoms to improve
Interpersonal therapy (IPT)
Risk assessment
16
Q
Which antidepressant SSRI should be used in patients with chronic health conditions and why?
A
Consider Citalopram or sertraline as lower propensity for interactions
17
Q
Which SSRI antidepressant is associated with a higher incidence of discontinuation symptoms
A
Paroxetine
18
Q
Which antidepressant should be given to children as a first line?
A
fluoxetine
19
Q
Which antidepressant has a risk of prolonging the QT interval?
A
Citalopram/escitalopram
20
Q
Which SSRI should be given in pregnant patients?
A
Use citalopram or sertraline
Others lead to fetal cardiovascular abnormalities
21
Q
What are the TCA anticholinergic effects
A
Dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate, and decreased sweating
22
Q
Which TCA’s have the most and the least side effects such as cardiotoxicity and anticholinergic effects?
A
Lofepramine - least
Imipramine - most
23
Q
Which antidepressants can help with weight gain in a patient with a low BMI?
A
alpha 2 adrenorecepetor antagonist - mirtazepine
24
Q
Which type of food should patients avoid if they are taking MAOi and why?
A
Do not eat food or drinks that contain TYRAMINE because this can cause hypertensive crisis
E.g., cheese, liver and yoghurt
25
What is dysthymic disorder?
- Chronic moire than 2 years with depressive symptoms, which is less severe more more chronic
26
What are the clinical features of dysthymic disorder?
clinical features similar to depression
Depressed mood, reduced/increased appetite, insomnia/hypersomnia, reduced energy/fatigue, low self-esteem, poor concentration, difficulties making decisions and thoughts of hopelessness
27
What is the management for dysthymic disorder?
SSRI/TCA, CBT may be useful
28
What are the clinical features of seasonal affective disorder?
Clear seasonal pattern to recurrent depressive episodes
Usually January/February (‘winter depression’)
Low self-esteem, hypersomnia, fatigue, increased appetite/weight gain
Decreased social and occupational functioning
Symptoms mild-moderate
29
What is the management for seasonal affective disorder?
Light therapy
2hrs 2500lux light in the morning for 1-2 weeks
Maintenance 30 mins 2500lux every 1-2days
then SSRI
30
What is the definition of post-natal depression?
Significant depressive episode related to childbirth (<6 months post-partum)
31
What are the risk factors for postnatal depression?
FHx depression, older age
Single mother, poor maternal relationship
Ambivalence to pregnancy, poor social support, and severe baby blues (low mood after childbirth 30-80% of patients get this in the first-week post-delivery)
32
What are the additional clinical features found in post-natal depression?
worries about babies health or ability to cope adequately with the baby
33
What is the assessment for post-natal depression?
Psychiatric screen
MSE
Edinburgh postnatal depression screen (EPDS) then PHQ-9
34
What is the treatment for post-natal depression?
SSRI (e.g., paroxetine, sertraline or citalopram) ± CBT
these are used as they give the lowest levels in breast milk
in severe cases inpatient admission to mother and baby unit
35
What is the definition of generalized anxiety disorder?
Excessive worry/feelings of apprehension about everyday events/problems leading to significant distress/functional impairment.
36
What are the criteria for diagnosis of generalised anxiety disorder?
--> Excessive anxiety and worry about everyday events/activities and difficulty controlling the worry on most days for 6 months
--> Should cause clinically significant distress/impairment in social, occupational or other important areas of functioning
--> At least 3 associated symptoms
37
what are the generalised anxiety disorder-associated symptoms?
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
derealisation
de-personalisation
Somatic features --> due to increased sympathetic tone include sweating, palpitations, dry mouth and a feeling of chest constriction
38
What is the assessment for generalised anxiety disorder?
Psychiatric history + MSE + GAD-7 questionnaire
39
What is the NICE stepwise care model for treating generalised anxiety disorder?
-->Education about GAD and treatment options with active monitoring
--> Individual non-facilitated or guided self-help and psycho-educational groups
--> CBT ± SSRI (sertraline first-line Second line: alternative SSRI or SNRI (venlafaxine – --> higher risk of toxicity, and duloxetine/ Third line: pregabalin)
--> CBT + SSRI (± input from multi-agency teams, crisis services, day hospitals or inpatient care)
40
Which drugs should not be offered to patients presenting with generalised anxiety disorders?
Benzodiazepines
Antipsycotics
41
What is the definition of panic disorder?
Recurrent, episodic, severe panic attacks that are unpredictable and NOT restricted to a particular situation/circumstance
42
What is the clinical presentation of panic disorder?
Symptoms peak within 10mins
Discrete episodes of intense fear
Autonomic arousal (PANICS Disorder)
P – Palpitations
A – Abdominal distress
N – Numbness/nausea
I – Intense fear of death
C – Choking/chest pain
S – Sweating/shaking/SOB
D – depersonalization/derealization
43
What are the investigations for panic disorder?
Psychiatric Hx + MSE
Blood: FBC, TFTs and glucose
ECG: sinus tachycardia
Rule out GAD with GAD-7
44
What is the treatment for panic disorder?
SSRIs (e.g., sertraline) > TCA (e.g. imipramine)
Don’t give BDZ!
CBT and self-help methods
45
Define phobic anxiety
Recurring excessive and unreasonable psychological or autonomic symptoms of anxiety in the (anticipated) presence of specific feared objects, situation, place or person leading, wherever possible to avoidance’
46
what are the 5 subtypes of phobic anxiety?
Animals
Aspects of the natural environment
blood/injury/injection
Situation
47
What is the management for phobic anxiety?
Behavioural therapy - graded exposure therapy
Education/anxiety management
BDZ e.g diazepam can help engage pt in exposure
48
What is the definition of PTSD?
Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
49
What is the clinical presentation (classic quadrad) for PTSD?
Reliving the situation
Avoidance - avoiding reminders of the event
Hyperarousal - irritability, outbursts and difficulty sleeping/concentrating
Emotional numbing - negative thoughts about oneself, difficulty expressing emotion and feeling detached from others.
50
What is dissociative amnesia?
inability to remember an important aspect
51
What is the criteria for a diagnosis of PTSD?
Exposure to a traumatic event, classic quadrad features present within 6 months of the event, features last > 1 month.
52
What are the investigations for PTSD?
psychiatry history
MSE
trauma screening questionnaire (TSQ)
53
What is the treatment for PTSD?
First-line: Trauma-focused CBT + Eye movement desensitization and reprocessing (EMDR)
Sertraline/venlafaxine
Zopiclone - sleep distrubances
54
What is the definition of OCD?
a chronic condition, associated with marked anxiety and depression, characterized by ‘obsessions’ and/or ‘compulsions’
55
What is an obsession?
An idea, image or impulse recognized by patients as their own, but which is experienced as repetitive, intrusive and distressing
Aggressive: images of hurting a child or parent
Contamination: becoming contaminated by shaking hands with another person
Need for order: intense distress when objects are disordered or asymmetric
Repeated doubts: wonder if a door was left unlock
Sexual imagery: recurrent pornographic images
56
What is a compulsion?
behaviour or action recognised by patient as unnecessary and purposeless but which they cannot resist performing repeatedly.
Repetitive ritualistic activities performed to alleviate anxiety from obsession
Drive to perform action is recognised by the patient as their own
Checking = repeatedly checking locks, alarms, appliances
Cleaning = hand washing, which is typically overt due to obvious dermatological symptoms
Mental acts = counting and repeating words silently
Ordering = reordering objects to achieve symmetry
There is non passivity, differentiating it from schizophrenia
57
What are the causes of PTSD?
Developmental factors, psychological factors and stressors
58
What is the criteria for diagnosis of OCD?
Presence of either obsessions, compulsions, or both.
Obsessions/compulsions are time-consuming ( >1hr/day) or cause clinically significant distress/functional impairment
At some point patient recognises the symptoms to be excessive/unreasonable
59
what questions can you ask to screen for OCD?
Do you wash or clean a lot?
Do you check things a lot?
Is there any thought that keeps bothering you that you would like to get rid of but cannot?
Do your ADLs take a long time to finish?
Are you concerned about putting things in a special order or are you very upset by mess?
Do these problems trouble you?
60
What is the treatment for OCD
CBT + exposure and response prevention (ERP)
Behavioural therapy/psychotherapy (supportive)
Pharmacological approach: SSRI (first-line), clomipramine (second-line)
61
What is the definition of Bipolar disorder?
Depression + mania/hypomania occurring in episodes usually with months separating them.
Diagnosis requires at least 1 episode of mania or hypomania
62
What are the possible causes of Bipolar disorder?
Personality
childhood experiences
life events
biochemical/endocrine correlates of depression
63
What is Mania?
Elevated, expansive, euphoric, or irritable mood with ≥3 characteristic symptoms of mania on most days for 1 week
64
What are the symptoms of Mania?
Elevated mood and increased energy
Pressure of thought, flight of ideas, pressure of speech and word salad (increased energy)
Increased self-esteem (over-familiarity, grandiosity, overly optimistic) and reduced attention
Tendency to engage in risky behaviour (Preoccupation with extravagant, impracticable schemes, Spendy recklessly, Inappropriate sexual encounters)
Other: excitement, irritability, aggressiveness and suspiciousness
Marked disruption of work, social activities and family life
65
What are the psychotic symptoms seen in manic episodes?
Occur in up to 75% of manic episodes
Grandiose delusions e.g., special powers
Persecutory delusions may develop from suspiciousness
Auditory and visual hallucinations
Catatonia i.e., manic stupor
Total loss of insight
66
What is the criteria for a diagnosis of hypomania?
≥3 characteristic symptoms lasting ≥4 days and be present most of the day, almost every day
67
What are the symptoms of hypomania?
Shares mania symptoms
Symptoms evident to lesser degree
Not severe enough to interfere with social or occupational functioning
Does not result in hospital admission
No psychotic features
Mildly elevated, expansive, or irritable mood
Increased energy
Increased self-esteem
Sociability
Talkativeness
Over-familiarity
Reduced need for sleep
Difficulty focusing
68
What is Bipolar I disorder?
characterised by episodes of depression, mania or mixed states separated by periods of normal mood
69
What is Bipolar II disorder?
do not experience mania but have periods of hypomania, depression or mixed states
70
What is Cyclothymic disorder?
characterised by recurring depressive and hypomanic states, lasting for at least 2 years, that do not meet the diagnostic threshold for a major affective episode
71
Give examples of medication that can induce mania/hypomania
TCAs/NSRIs > SSRIs
benzodiazepines
antipsychotics
anti-Parkinsonian medications
72
What is the pharmacological treatment for Bipolar disorder?
Manic episode: lithium ± benzodiazepine (e.g., clonazepam or lorazepam)
Depressive episode: SSRI - least likley to induce mania
Maintenance: Lithium/ Carbamazepine
73
What are the side effects of Lithium and why can they be common?
Lithium has a narrow therapeutic range
weight gain
subclinical/clinical hypothyroidism
renal impairment
teratogenic - Ebstein's anomaly - congenital malformation of the tricuspid valve
74
What is the therapeutic level for Lithium?
0.6-0.8 mmol/L
75
What type of drug is Lithium/carbamazepine?
mood stabilisers
76
What are the psychotherapeutic interventions for Bipolar disorder?
Psychoeducation
CBT
IPT
Support groups
77
What are the risk factors for Schizophrenia?
Bimodal distribution – 2nd-3rd decade and middle-age peaks
Family history of schizophrenia
Pre-morbid schizoid personality – abnormal shyness, eccentricity, fanaticism
Abuse – physical, sexual, emotional
Delayed developmental milestones
Obstetric – LBW, prem delivery, asphyxia
Substance abuse – cannabis, cocaine, LSD and amphetamines
Significant life event
Cerebral injury – trauma, tumour, disease
Acute psychosis – illness, surgery, reduced sleep
78
How can the symptoms of schizophrenia be grouped?
Positive symptoms - new feature that doesn’t have a physiological counterpart
Negative symptoms - removal of normal processes, can be a decrease of emotions or loss of interests anhedonia
Cognitive symptoms - not being able to remember things, learn new things or understand others, subtle and difficult to notice
79
What are the positive symptoms of schizophrenia?
o Auditory hallucinations --> 2nd or 3rd person, in or out of head, Command, derogatory, running commentary
o Delusions:
False, unshakeable belief not in patients' social/religious/cultural background
Beliefs - persecutory, grandiose, nihilistic, religious, referential, perceptive
Thoughts – insertion, withdrawal, broadcast
o Bizarre/disorganised/catatonic behaviour
o Tangentiality -> loosening of association
o Circumstantiality
o Speech:
Pressured, distractible
Verbigeration – obsessive repetition of random words
Perseveration – staying on the same topic with different stimuli
Word salad – random words with no connections
Disorganised speech
o Catatonic behaviour
80
What are the negative symptoms of schizophrenia?
tend to be prodromal
* Avolition – decreased motivation
* Anhedonia
* Asocial behaviour
* Blunting/incongruity of affect
* Alogia – poverty of speech
* Depression
81
What are the cognitive symptoms of schizophrenia?
not being able to remember things, learn new things or understand others, subtle and difficult to notice
82
What is the DSM-V diagnostic criteria for schizophrenia?
Two of the following:
Delusions -->At least one
Hallucinations --> At least one
Disorganised speech --> At least one
Disorganised/catatonic behaviour
Negative symptoms
Ongoing for 6 months
Not due to another condition - e,g drug abuse
83
What are the first rank symptoms of schizophrenia?
Hallucinations - 2 or more voices, talking about patient in 3rd person
Delusional perception
Passivity phenomena - bodily sensations controlled by external influence
Thought disorder - withdrawal/broadcasting/insertion
84
What are the second rank symptoms of Schizophrenia?
paranoid persecutory and referential delusions, -ve symptoms
85
What are the differentials for Schizophrenia?
Psychotic depression
Schizoaffective disorder
Personality disorder
Bipolar disorder
substance abuse
86
What are the investigations for schizophrenia?
Full psychiatry Hx + MSE
Exclude differentials --> psychotic depression, schizoaffective disorder, personality disorder, Bipolar disorder, substance abuse
Exclude physical causes --> Scans - CT/MRI head, toxicology screen, blood - FBC/U&E/LFT
87
What is schizoaffective disorder?
Mood disorder + schizophrenia
88
What are the different types of schizoaffective disorder?
Manic type – manic + psychotic symptoms
Depressive type – depressive + psychotic symptoms
Mixed type – depressive + manic + psychotic symptoms
89
What are the risk factors for schizoaffective disorder?
Family history of schizophrenia
substance abuse
psychological stress/environment
90
What are the symptoms of schizoaffective disorder?
SCHIZOPHRENIA
Negative – anhedonia, social isolation, blunt affect
Positive - Hallucinations – auditory, visual, tactile
Positive - Delusions – persecutory, nihilistic, grandiose, religious
Positive - Thought disorder – tangential thinking, verbigeration
Cognition - Memory/executive function deficits
PSYCHOTIC DEPRESSION
91
What is the management of schizoaffective disorder?
Antipsychotic – risperidone, aripiprazole, quetiapine
Anxiolytic – lorazepam
Psychological interventions – CBT
Social intervention – housing, employment, exercise, education
PSYCHOTIC DEPRESSION
Medication – antidepressants + antipsychotics
Non-pharmacological – CBT, lifestyle changes, housing/employment help
92
What is the pharmacological treatment for Schizophrenia?
Antipsychotics (PO or depot):
Atypical:
- Risperidone
-Quetiapine
-Aripiprazole
-Olanzapine
-Clozapine
Typical:
-Haloperidol
-Chlorpromazine
93
What are the side effects of antipsychotic use?
Extra-pyramidal – akathisia, tardive dyskinesia, dystonia, NMS
Metabolic – weight gain, diabetes, liver dysfunction
General – dry mouth, constipation, sexual dysfunction, ECG changes
Specific:
Risperidone – hyperprolactinaemia
Clozapine – agranulocytosis, cardiomyopathy
Drowsiness/sedation
QT interval prolongation
GI disturbances
94
Which antipsychotic can cause hyperprolactinaemia?
Risperidone
95
Which antipsychotic can cause agranulocytosis and cardiomyopathy?
Clozapine
96
Name 3 mood stabiliser drugs
Lithium, carbamazepine, sodium valporate
97
Name 2 anxiolytic drugs
Clonazepam/diazepam
98
What are the non-pharmacological management options for schizophrenia?
Manage mental health co-morbidities
CBT
Family therapy
Art therapy
Lifestyle changes
ECT - electroconvulsive therapy
99
What is the duration of section 2 of the mental health act?
28 days and non-renewable
100
What is the purpose of section 2 of the mental health act
assessment and treatment
101
Which professionals can authorise section 2 of the mental health act?
Two doctors one of which who is section 12 approved
One approved mental health professional AMHP
102
Why might a patient be sectioned under section 2 of the mental health act?
Patient may be suffering from mental disorder
and detained for their own health/safety or others protection.
103
What is the duration of section 3 of the mental health act?
6 months and renewable
104
What is the purpose of placing a patient on section 3 of the MHA?
long term treatment
detained for their own health/safety or others protection.
105
Which professionals can authorise section 3 of the mental health act?
Two doctors one of which who is section 12 approved
One approved mental health professional AMHP
106
What is the duration of section 4 of the mental health act?
72 hours, non-renewable
107
What is the purpose of placing a patient on section 4 of the MHA?
To hold the patient until assessment by a s12 doctor
108
Which professionals can authorise section 4 of the mental health act?
One doctor
One AMHP
109
What are the two different types of Section 5 MHA?
Section 5(4)
Section 5(2)
110
What is the purpose of section 5 MHA?
patient is in hospital but wants to leave, cannot be treated coercively
111
What is the duration of section 5(4) and who is it initiated by?
6 hours
Nurse
112
What is the duration of section 5(2) and who is it initiated by?
72 hours
doctor in charge of the patient care
113
What are the two police orders?
135 and 136
114
What is the duration and purpose of order 135?
Duration – 36 hours
Purpose - police allowed to enter patient’s home to move to a place of safety
115
What is the duration and purpose of order 136?
Duration – 24 hours
Purpose – police can move patient with mental disorder in a public place to place of safety
116
What is the pathophysiology of neuroleptic malignant syndrome?
Adverse reaction to dopamine receptor agonists - antipsychotics
Abrupt withdrawal of dopaminergic medication - parkinson's
117
What are the symptoms of neuroleptic malignant syndrome?
Altered mental state – confusion, delirium, stupor
Hypertonia/muscle rigidity – lead pipe rigidity!!
Autonomic dysfunction – high HR, high RR, urinary incontinence, labile BP, sweating
Hyperthermia - high fever
118
What are the investigations for Neuroleptic malignant syndrome?
Rule out differentials (sepsis, brain problems, renal failure):
Bloods – FBC (WCC high in NMS), CK (NMS -> rhabdomyolysis), U and Es
Imaging – CT/MRI head
Infection screen - urine/blood culture, LP
119
What is the management of neuroleptic malignant syndrome?
Withdraw anti-psychotic medication
Supportive treatment - rehydration, correct U and E imbalances, antipyretics
120
What is the pathophysiology of Serotonin Syndrome?
increased intrasynaptic serotonin concentration
121
What are the causes of Serotonin Syndrome?
Antidepressants – SSRI and SNRI
Others – opioid analgesics, MAOI, lithium
122
What are the symptoms of serotonin syndrome?
Altered mental state - anxiety, agitation, confusion
Neuromuscular – clonus, hyperreflexia, hypertonia, tremors IMPORTANT
Autonomic – high HR and RR, sweating, shivering, D and V, hyperthermia
123
What are the investigations for serotonin syndrome?
Look for other causes
124
What is the management for serotonin syndrome?
Withdraw offending medication
Supportive treatment – benzos for agitation, cool pt down
If a recent overdose – activated charcoal
125
What is the definition of personality disorders?
An enduring pattern of inner experience and behaviour that deviated markedly from the expectations of the individual’s culture.
126
According to DSM-5 generally, the diagnosis of personality disorder includes...
long-term marked deviation from cultural expectations that leads to significant distress or impairment in at least two of these areas:
- Cognition = the ways of perceiving and interpreting self, other people and events
- Affectivity = the range, intensity, lability, and appropriateness of the patient's -
- emotional responses
- Interpersonal functioning
- How well the patient controls their impulses
127
What are cluster A personality disorders?
Paranoid
Schizoid
Schizotypal
128
What can be the causes of personality disorders?
Socioeconomic status
Family history
Parenting/deprivation
Abuse
129
What would you see in someone with a paranoid personality disorder?
--> Irrational belief that others are harmful or deceptive
--> Doubts the trustworthiness of close individuals
--> Reluctance to confide in others, fearing it may be used against oneself
--> Sees hidden threats in everyday scenarios
--> Hold prolonged grudges
--> Constantly feels attacked
--> suspicious of partners fidelity
--> not explained by any other condition or substance
130
What would you see in someone with a schizoid personality disorder?
--> does not want/enjoy close relationships
--> prefers solitude
--> lack of interest in sexual activities
--> Hard to please
--> lacks close friends
--> unbothered by other's comments
--> flat affect/emotional blunting
--> not explained by any other condition/substance
131
What would you see in someone with a schizotypal personality disorder?
--> ideas of reference - everything relates to destiny
--> magical thinking that changes behaviour - random events are linked
--> altered perception
--> unusual thinking/talking
--> suspiciousness/paranoia
--> Inappropriate/flat affect
--> eccentric/unusual behaviour
--> lack of close friends
--> social anxiety - paranoia
132
What are the cluster B personality disorders?
Antisocial
Borderline
Histrionic
narcissistic
133
What would you see in someone with an antisocial personality disorder?
--> does not conform to societal norms and disregards moral values
--> Deceitful
--> impulsive/aggressive
--> reckless
--> irresponsible
--> unremorseful
--> little empathy
134
What would you see in someone with a borderline personality disorder?
--> Frantic avoidance of abandonment
--> Unstable, intense relationships
--> unstable self-image
--> Self-destructive impulsivity
--> Suicidal/Self-harming behaviour
--> Emotional instability
--> feeling empty
--> anger management issues
--> transient paranoid thinking
--> splitting, extreme perspective on important things such as good or bad
135
What would you see in someone with a histrionic personality disorder?
--> attention seeking must be the centre of attention
--> inappropriate such as provocative interactions
--> fast changing shallow emotions
--> uses appearance to draw attention
--> vague speech
--> exaggerated manner
--> easily affected by others/situation
--> mistakes relationships as being more intimate
136
What would you see in someone with a narcissistic personality disorder?
--> grandiose self-image
--> fantasies of grandiosity
--> Believes they are special
--> Seeks admiration
--> sense of entitlement
--> exploitative
--> envious/jealous
--> arrogant
137
What are cluster C personality disorders?
Avoidant
Obsessive-compulsive
dependant
138
What would you see in someone with an avoidant personality disorder?
--> avoids social situations
--> unwillingness to interact
--> limits intimate relationships
--> Preoccupation with rejection, criticism
--> low self-esteem
--> fears embarrassment associated with social risk-taking
139
What would you see in someone with Obsessive-compulsive personality disorder?
--> preoccupation with details
--> Disruptive perfectionism
--> Work eclipses personal life
--> Rigid, loud beliefs (religious, ethical)
--> tendency of hoard possesions
--> refuses to delegate
--> excessively frugal
--> stubborness
140
What is the difference between Obsessive-compulsive disorder and obsessive-compulsive personality disorder?
OCD --> anxiety disorder - repetition of ritualistic actions, Ego-dystonic - patient wishes they could stop
OCPD --> Ego-syntonic - happy with how they are
don't want to change
141
What would you see in someone with a dependent personality disorder?
--> cant make everyday decisions
--> overly dependent on others
--> Scared to disagree with others
--> Lacks self-motivation
--> craves approval
--> uncomfortable/afraid of being alone
--> Quick to replace lost relationships
142
What investigations would you carry out for personality disorders?
Psychiatric history + MSE
Personality diagnostic questionnaire (PDQ-IV)
Minnesota multiphasic personality inventory
MRI/CT head
143
At what age can a diagnosis of personality disorder be made and why?
>18 years
as this is when the personality has developed
144
What is the management of someone with a personality disorder?
--> Risk assessment
--> No specific pharmacological treatment- Can help treat symptoms, Antidepressants/beta-blockers (propranolol) to treat depression or anxiety, Mood stabilisers/antipsychotics can be prescribed to help mood swings, alleviate psychotic symptoms or reduce impulsive behaviour
--> Dialectical behavioural therapy (DBT)
--> Mentalisation-based therapy (MBT)/CBT/psychodynamic therapy
--> Crisis team
145
What are two examples of physiological dependence in drug abuse?
--> sign of tolerance
--> Withdrawal symptoms
146
What are the criteria for diagnosing a patient with drug abuse?
THREE OR MORE OF THE FOLLOWING MUST OCCUR FOR >1MONTH
Desire for substance
Preoccupation with substance use
Withdrawal state
Incapability to control substance
Tolerance to substance
Evidence of harmful effects
147
What are the potential complications of drug abuse?
--> Death
--> infection (e.g., IE)
--> DVT
--> PE
--> craving
--> anxiety
--> cognitive disturbance
--> drug-induced psychosis, crime
--> imprisonment
--> homelessness
148
What are the investigations for substance (drug) abuse?
Psychiatric Hx + MSE
Physical exam: weight, dentition, signs of IVDU
Signs of withdrawal
Bloods: FBC, U&Es, LFTs, clotting profile, drug level and screen for blood-borne infections (Hep B&C, HIV)
Urinalysis: toxicology
ECG, echocardiogram and CXR
149
What are the signs of opiate withdrawal?
Appear 6-24hours after the last dose
Last 5-7 days
Sweating, dilated pupils, tachycardia, high BP, watering eyes/nose, abdominal cramps, N&V, tremor and muscle cramps
150
What is the management of substance (drug) abuse?
Self-help groups
Motivational interviewing/CBT
Pharmacological intervention: opioid dependence
Substitute prescribing/detoxification: Methadone, buprenorphine ( withdrawal side effects lower) or dihydrocodeine
Withdrawal symptom relief: Lofexidine - used in younger patients
Relapse prevention: Naltrexone
Overdose: Naloxone
Benzodiazepine substitute prescribing/detoxification: long-acting diazepam
151
How do you calculate alcoholic units?
(ABV (%) X volume (ml)) /1000
152
What is the recommended unit intake of alcohol per week?
14 units/week
153
What is the clinical presentation of intoxication?
Impaired speech, labile affect, impaired judgement, poor coordination, hypoglycaemia, stupor and coma
154
What are the clinical signs of alcohol dependence?
S – Subjective awareness of compulsion to drink
A – avoidance or relief of withdrawal by further drinking
W – Withdrawal symptoms
D – Drink-seeking behaviour
R – Reinstatement of drinking after attempted abstinence
I – Increased tolerance
N – Narrowing of drinking repertoire - Start off by drinking beers, cider, ales and wine, then only drinks spirits
155
What occurs in alcohol withdrawal?
Symptoms appear 6-12hrs after the last drink
--> Malaise, tremors, nausea, insomnia, transient hallucination and autonomic hypersensitivity
At 36 hours
--> Seizures
At 72 hours
--> Delirium tremens
156
What are the signs of Delirium tremens (DT)
Acute confusional state
Dehydration ± electrolyte disturbances
Cognitive impairment
Hallucinations/illusions
Paranoid delusions
Marked tremor
Autonomic arousal
157
Why can alcohol withdrawal cause delirium tremens?
chronic alcohol consumption enhances GABA-mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
158
Name 2 complications of alcohol misuse
Wernickes encepahlopathy
Wernick-Korsakoff syndrome
159
Why does Wernicke's encephalopathy occur?
Thiamine Vitamin B1 deficiency
160
What is the clinical presentation of Wernicke's encephalopathy?
Triad of:
--> Encephalopathy (confusion, disorientation, indifference, and inattentiveness)
--> Ophthalmoplegia/nystagmus
--> Ataxia
161
What is the treatment for Wernicke's encephalopathy?
IV Pabrinex (thiamine)
162
What can untreated Wernicke's encephalopathy lead to?
Wernick-Korsakoff syndrome
163
What is the clinical presentation of Wernick-Kosakoff syndrome?
--> Retrograde amnesia - loss of memories that have been already formed
--> Anterograde amnesia - inability to form new memories
--> Confabulation - the creation of false memories without the intent to deceive
--> disorientation to time
164
What is the management of Wernick-Korsakoff syndrome?
- not curable
- PO thiamine and multivitamins for 2 years
165
What is the assessment for alcohol misuse?
--> Psychiatric Hx + MSE
--> Physical exam - attention to chronic liver disease peripheral stigmata - palmar erythema, Dupuytrens contracture, spider naevi, gynae
--> Questionnaires: AUDIT (Alcohol Use Disorders Identification Test)
, CAGE (cut down, annoyed when questioned, guilty drinking, eye-opening event)
, SADQ (severity of alcohol dependence questionnaire)
and FAST (fast alcohol screening test)
--> Clinical Institute Withdrawal Assessment (CIWA) - determines withdrawal severity
--> CT head
--> ECG
--> Bloods: FBC, U&Es, LFTs (gamma-GT^), TFTs, vitamin B12/folate, blood alcohol level, amylase/lipase, glucose and hepatitis serology
166
What is the treatment for alcohol misuse and withdrawal?
Alcohol withdrawal: Chlordiazepoxide + IV Thiamine (Give Lorazepam if liver disease)
Long term management of alcohol use disorder: Acamprosate (reduces cravings)
Naltrexone (reduces pleasurable effects of alcohol)
Disulfiram (causes unpleasant symptoms when drinking)
Motivational interviewing/CBT
Alcoholics Anonymous
Oral thiamine
167
What is the definition of Dementia?
progressive neurological disorder impacting cognition that leads to functional impairment
168
What are the different types of dementia?
--> Alzheimer’s disease - senile plaques, neurofibrillary tangles, neuronal loss
--> Vascular dementia - microinfarcts in cerebral blood vessels -> poor blood supply
--> Lewy body dementia - abnormal deposits of alpha-synuclein -> Lewy bodies
Others:
-Frontotemporal
-Parkinson’s related
-Alcohol-related
-Mixed (Alzh + vasc)
169
What are the risk factors for dementia?
Age > 65
Family history
Genetics – presenilin
Down’s syndrome
Cerebrovascular disease
Hyperlipidaemia
Lifestyle – smoking, obesity, high-fat diet, alcohol
Poor education
170
What are the general symptoms of dementia?
Memory decline – new memories lost first
Disoriented in time and place
Nominal dysphasia – can’t name objects/people
Visuospatial dysfunction – misplacing things/getting lost
Change in emotions – apathy or disinhibition
Change in personality
Prosopagnosia – unable to recognise faces
171
What are the symptoms of Alzheimer's disease?
Gradual onset + progressive
No insight into the condition
172
What are the symptoms of vascular dementia?
Stepwise progression
Insight into condition
173
What are the symptoms of Lewy-body dementia?
Hallucinations common
Parkinsonian signs - hypertonia, bradykinesia, resting tremor
174
What are the investigations for dementia?
--> Full history – personal and collateral
--> Cognitive screening tools:
- MMSE
- ACE III
- MoCA
--> Rule out medical causes:
- Bloods – FBC, metabolic panel, B12, LFT, BM
- Urinalysis
- CT/MRI head
--> Differential diagnosis:
-Delirium
-Depression
175
What is the management of dementia
--> Advance care plan – LPA, advance statement, preferred place of care
--> Pharmacological:
- Acetylcholinesterase inhibitors:
- Donepezil
- Galantamine
- Rivastigmine
- Other psychiatric disturbances – antipsychotics/antidepressants/anxiolytic
--> Non-pharmacological:
- Lifestyle changes - diet, exercise, maintaining social contacts
- Cognitive rehabilitation/occupational therapy
176
What is delirium?
acute, fluctuating change in mental state
177
What are the different types of Delirium?
hyperactive - restlessness, agitation, delusion/hallucination
hypoactive - lethargy, sedation, slow to respond
mixed - hyperactive + hypoactive
178
What are the potential causes of Delirium?
PINCH ME
--> Pain – MI, surgery, iatrogenic, neurological problem
--> Infection – meningitis, UTI, fever, pneumonia, sepsis
--> Nutrition – decreased oral intake, metabolic abnormalities
--> Constipation
--> Hydration – dehydration
--> Medication – polypharmacy, change in medication, withdrawal (benzo, alcohol)
--> Environment – dementia, use of restraints, catheter
179
What is the management of Delirium?
Treat the cause
180
What is autism spectrum disorder?
A developmental disorder is characterised by difficulties with social interactions, and communication as well as restricted repetitive behaviours, interests and activities
The spectrum encompasses Aspergers syndrome, childhood disintegrative disorder
181
What are the causes of autism spectrum disorder?
Genetic and environmental
182
What are the signs and symptoms of autism spectrum disorder?
--> Struggles with social interaction/communication
--> poor emotional reciprocity - doesn't respond to/communicate emotions, thoughts
--> poor non-verbal communication
--> don't share interests with others
--> difficulty in maintaining/developing relationships
--> repetition of particular movements/phrases
--> specific routines/rituals and resistant to change
--> Restricted interests - highly specific knowledge of a subject
--> Highly sensitive to/interested in surroundings
183
What are the complications of autism spectrum disorder?
Reduced success in various areas of life such as social and academic
184
What is the management for autism spectrum disorder?
Educational programs and behavioural therapy tailored to that individual
185
What is Somatisation disorder?
Extended periods of unexplained physical symptoms, normally over 2 years. Not faking symptoms, unlike factitious disorder.
the patient refuses to accept reassurance or negative test results
186
What are the signs and symptoms of somatisation disorder?
- Somatic symptoms --> pain, sexual, gastrointestinal problems which can change over time
- Cognitive symptoms --> worry and anxiety due to the physical symptoms not being able to be explained, excessive thought about the severity of symptoms, anxiety about symptoms/health.
187
What does somatisation disorder have a high co-morbidity with?
depression and anxiety disorders
188
What is the diagnostic criteria for somatisation disorder?
one or more than one somatic symptom and distress in other areas of life related to the anxiety and worry caused by the unexplained symptoms lasting more than 6 months
189
How is the severity of somatisation disorder determined?
- determined by changes in cognitive symptoms
- mild --> one change
- moderate --> two or more changes
- severe --> two or more changes with multiple physical symptoms/one severe symptom
190
What is the treatment for somatisation disorder?
Psychotherapy - to improve cognitive symptoms e.g group therapy.
191
What is psychosis?
is a term used to describe a person experiencing things differently from those around them.
192
name some psychotic features
Psychotic features include:
hallucinations (e.g. auditory)
delusions
thought disorganisation
alogia: little information conveyed by speech
tangentiality: answers diverge from the topic
clanging
word salad: linking real words incoherently → nonsensical content
193
Which neurological conditions can present with psychotic symptoms?
Parkinson's disease
Huntingtons disease
194
Give an example of a prescribed drug that can induce psychosis.
corticosteroids
195
Which neurological conditions can present with psychotic symptoms?
Parkinson's disease
Huntington's disease
196
What is the ECT?
Electroconvulsive therapy, also known as ECT, is a psychiatric treatment in which a patient is put to sleep and a small amount of electrical energy is directed toward the brain which induces a controlled minor seizure. This is thought to alter chemical imbalances in the brain, therefore reducing the severity of psychological illness.
197
What can ECT be used to treat?
Severe depression which is resistant to multiple antidepressants
Severe depressive disorder which is causing harm to the patient (e.g. associated with self-neglect/suicide risk)
Catatonia
198
What is the duration of an ECT course?
usually comprises of 6-12 treatments given twice weekly and the patient is reassessed after every treatment. If improvements aren’t noted after 6 sessions of ECT, the course may be stopped.
199
What are some of the side effects of ECT?
Short-term memory loss
Retrograde amnesia (memory loss immediately before/after ECT)
Post ECT headache
Brief confusion/drowsiness following administration of the anaesthetic
200
What would you see in a patient with a learning disability?
Difficulty with developing/learning certain skills
201
What are the different types of learning disabilities?
Dyslexia - difficulty reading
Dysgraphia - difficulty writing
Dyscalculia - difficulty with mathematics
202
What is the complications of learning disabilities?
Reduced success in various areas of life
203
What are the signs and symptoms of learning disabilities?
Dyslexia - slow, effortful reading and poor understanding
Dysgraphia - poor spelling, grammar, handwriting
Dyscalculia - poor arithmetic
often co-morbid with anxiety, depression
204
How is a diagnosis of a learning disability reached?
more than or one of the following for 6 months or more
--> Poor reading skills
--> Poor reading comprehension
--> difficulties with spelling
--> other difficulties with written language
--> trouble with mathematics
--> trouble with mathematical reasoning
--> academic skills significantly lower than what would be expected through testing
--> Must be present during school years, may not be problematic later on
--> not caused by any other condition or environmental condition
205
What are the treatment options for learning disabilities?
--> modified approaches to education e.g 1-1 tuition
--> specific techniques/workarounds dependant on symptoms such as using specific fonts to alleviate dyslexia
206
What are persecutory delusions?
This type causes a person to believe that someone or something is "out to get them." This can include another person, a machine, or an entire institution or organisation.
considered to be an extreme form of paranoia
207
What are erotomanic delusions?
Erotomanic delusions cause a person to believe (falsely) that another person—or many people—are in love with them. The person who is the target of erotomanic delusions is usually of "higher status" than the person with the delusions, and the targets are often celebrities
208
What are grandiose delusions?
People who have grandiose delusions believe that they are superior to other people. These beliefs can give a person a sense of belonging and self-worth.
209
What are delusions of reference?
A delusion of reference is the belief that un-related occurrences in the external world have a special significance for the person who is being diagnosed
210
What are nihilistic delusions?
the delusional belief of being dead, decomposed or annihilated, having lost one's own internal organs or even not existing entirely as a human being
211
What is passivity?
in which patients report that their actions or thoughts are influenced by, or under the control of, some external entity.
212
What is verbigeration?
obssesive repition of random words
213
What is perseveration?
staying on the same topic despite a change in stimulus
214
What is bulimia nervosa?
Bulimia nervosa is a type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising.
215
What are the DSM 5 diagnostic criteria for Bulimia Nervosa?
--> recurrent episodes greater than or equal to three months of binge eating (eating an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances)
--> a sense of lack of control over eating during the episode
--> recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, other medications, fasting, or excessive exercise. Recurrent vomiting may lead to erosion of teeth and Russell's sign-calluses on the knuckles or back of the hand due to repeated self-induced vomiting
--> the binge eating and compensatory behaviours both occur, on average, at least once a week for three months.
--> self-evaluation is unduly influenced by body shape and weight.
--> the disturbance does not occur exclusively during episodes of anorexia nervosa.
216
What is the management of Bulimia Nervosa?
--> psychotherapy - CBT
--> careful weight gain to avoid refeeding syndrome
--> Antidepressants - SSRIs
217
What are the signs and symptoms of Bulimia Nervosa?
--> Binge eating with compensatory behaviours e.g purposeful vomiting
--> endocrine changes --> menstruation stops/ never starts and increased risk of diabetes mellitus
--> if purging by vomiting -> enamel erosion, parotid gland swelling, bad breath, bruised/calloused knuckles (Russell's sign), stomach tearing, fast heartbeat, depletion of electrolytes
218
What is Anorexia Nervosa?
An eating disorder characterised by restrictive food intake leading to significantly low body weight. Patients experience fear of weight gain and have a distorted view of body, often beings in teens or early adulthood
219
What are the three different types of anorexia nervosa?
--> Atypical anorexia Nervosa
--> Restricting anorexia nervosa
--> Binge-eating/purging anorexia nervosa
220
What is atypical anorexia nervosa?
Label for individuals with anorexia symptoms without significantly low body weight
221
What is restricting anorexia nervosa?
individual loses weight by purging such as vomiting, using laxatives/diuretics/enemas
222
What are the potential complications of anorexia nervosa?
--> refeeding syndrome
--> difficulty breathing
--> heart failure
--> brain damage
--> suicidal ideation
--> death
223
What are the signs and symptoms of anorexia nervosa?
--> fear of weight gain --> restrictive food behaviours, purging, excessive exercise, weight checks and food rituals
--> Restrictive food intake --> electrolyte abnormalities, vitamin deficiencies, muscle loss, low creatinine levels, fatigue --> brain damage, weakened bones, dry/scaly skin, menstruation stops, difficulty breathing, slow heartbeat, hypotension, congestive heart failure, oedema, bone marrow shuts down - dampened immune system, low energy and easily bruised
-->if purging by vomiting -> enamel erosion, parotid gland swelling, bad breath, bruised/calloused knuckles (Russell's sign), stomach tearing, fast heartbeat, depletion of electrolytes
224
What is the diagnostic criteria for anorexia nervosa
--> restrictive food intake (leading to significantly low body weight)
--> if body weight can not be described as significantly low then the diagnosis will be atypical anorexia nervosa
--> fear of weight gain
--> distorted view of the body
--> restricting type: the individual has not repeatedly binge-eaten or purged over 3 months (instead attempts to restrict food intake/exercising excessively)
--> Binge-eating/purging anorexia nervosa : Repeated binge-eating/ purging over three months
